Certain payers require prior authorizations.
Depending on the payer, a home health agency (HHA) may be required to obtain a ‘prior authorization’ (PA) for home health billing and to determine insurance eligibility. Think of prior authorization as “permission” to provide a type of service for a specified duration. The purpose of prior authorization checks is to prevent unnecessary procedures as well as the prescribing of expensive brand name drugs when an appropriate generic is available. For more on home health billing click here.
Most Medicaid and commercial insurance companies (Humana, Aetna, Blue Cross/Blue Shield etc) require the HHA to obtain a prior authorization before providing services. If you don’t obtain a required PA, you won’t be paid for the services you provide. It’s important to provide services exactly according to the PA – payers will p
ay for only services that have been authorized.
Maintain a list of telephone numbers (for each payer) to call for Prior Authorization.
To get a PA you need to telephone the department of the payer that issues PAs. Typically you’ll receive a code or number that is associated with the authorization and that code/number will go on the invoice (‘claim’) that you mail or electronically submit.
For example, a Medicaid program that pays for PCA (personal care attendant) services requires that you, the HHA, get prior authorization before providing services. You'll telephone the department and obtain a PA to provide (for example) PCA services, 6 hours per week for 12 weeks starting on month/day/year. They’ll issue you a code to put on the invoice. When you create the invoice you’ll include the PA code on the invoice before home health billing.
Find a software to track your Prior Authorizations.
You’ll need a way to track if you are
- following the prior authorization (tracking the number of hours or visits authorized) and
- when a new prior authorization is due.
